Below are four scenarios.Read the scenario and type your responses to the questions.Hit send when you are finished with all of them.You will receive individualized feedback for each of your responses.

Pat is a first year resident who has just seen a patient with diabetes.She presents the patient to you:"Ms. K is a 45 year old woman with type 2 diabetes. She is here for her 3-month checkup and says she’s doing well. Her hemoglobin A 1C was 6.5 last week. Her blood sugars at home ranged from 70 to 150. She takes her metformin twice a day every day. Her last cholesterol showed an LDL of 120. On exam, her blood pressure is 140/90. Her HEENT exam is normal, heart and lungs are normal. I think her diabetes is under good control and I’d like to continue her current treatment."

Pat stops her presentation here.You notice that Pat has neglected important aspects of this patient's overall health, including her cholesterol and her diabetic foot exam. What do you say to Pat to get a more complete commitment? How about to probe for evidence? (Write what you would say to the resident in the box below.)

1. Getting a commitment:

2. Probing for supporting evidence:

Mohammed, a fourth year student, comes to you after seeing Mr. R, a 50 year old man."Mr. R came in today because his wife made him. He has no complaints. On review of systems he has no complaint of shortness of breath, chest pain, abdominal pain, bowel or bladder problems or joint pain. He reports he is healthy. His heart, lung, and abdominal exams are normal. He seems healthy to me."

Mohammed stops his presentation here. You notice that he has not asked the patient about any personal health habits, and he hasn't addressed health maintenance issues with this patient. How would you as a preceptor take this opportunity to teach Mohammed some general principles about preventive care? (Write what you would say to the resident in the box below.)

Teaching general principles:

Aisha is a third year resident who has just seen a patient with upper respiratory complaints.

"Ms. G is a 32 year old woman with a three day history of sore throat, headache, nasal congestion, and cough. She has tried over the counter decongestants with minimal relief. She denies fever, vomiting or diarrhea. No one else at home is sick. She has not traveled recently. Her last menstrual period was two weeks ago and was normal. She has otherwise been healthy, and takes no medications regularly. On exam, she is in no distress. Lungs were clear, heart was normal, throat was mildly red, nose was mildly congested. There was no sinus tenderness. The patient requested an antibiotic, but I think this is a viral illness. I explained to the patient the nature of viral URIs, and recommended continued symptomatic care."

Aisha stops her presentation here. You feel she has done a good presentation. How will you reinforce what Aisha has done well? (Write what you would say to the resident in the box below.)

Reinforcing what was done well:

Alfredo is a second year resident.

"Mr. Z is a 25 year old man who presents with pain in his lower back for the past two weeks. He is a construction worker and has been lifting cinder blocks at his work site. The pain doesn’t radiate. It is worse when he moves. It is not keeping him awake at night. He has been taking over-the-counter ibuprofen with moderate relief. He denies problems with his bowels or bladder. He denies weakness or sensory loss. On exam, he has tenderness in the paraspinal muscles in the low back. His straight leg raise test is negative. His gait is normal. Reflexes in the lower extremities are normal. I think this patient has a herniated disc, and I would like to send him for an MRI."

Alfredo stops his presentation here. You are concerned that Alfredo's plan is too aggressive for the patient's complaints and physical findings. How do you correct Alfredo’s errors or omissions? (Write what you would say to the resident in the box below.)